肺部超声评分评估急性呼吸窘迫综合征患者病情严重程度及预后的价值

摘要

ObjectiveTo evaluate the value of lung ultrasound score (LUS) on assessing the severity and prognosis in patients with acute respiratory distress syndrome (ARDS), and to investigate its correlation with oxygenation index, acute physiology and chronic health evaluationⅡ (APACHEⅡ) score, sequential organ failure assessment (SOFA) score, and clinical pulmonary infection score (CPIS), and other traditional parameters.Methods A prospective double-blind cohort study was conducted. Sixty-two ARDS patients conformed to the Berlin diagnostic criteria admitted to intensive care unit (ICU) of Beijing Huaxin Hospital from October 2013 to December 2014 were enrolled, including 14 cases with mild, 18 moderate, and 30 severe ARDS; among them 37 cases were of ARDS with pulmonary origin, and 25 non-pulmonary ARDS; 35 patients survived, and 27 died. The clinical data and scores of all patients were recorded by one specialized observer, including baseline data, hemodynamic parameters, lactate, respiratory parameters, and APACHEⅡ, SOFA and CPIS scores. Another observer of recording was responsible for the results of lung ultrasound, LUS, and echocardiogram. The correlation between LUS and oxygenation index as well as APACHEⅡ, SOFA and CPIS scores was analyzed by bivariate correlation analysis. Receiver operator characteristic curve (ROC) was plotted, and the predictive value, sensitivity and specificity of mild ARDS, moderate ARDS, severe ARDS and mortality by LUS were calculated. Results LUS had a negative correlation with oxygenation index (r = -0.755,P< 0.001), a good positive correlation with APACHEⅡ (r = 0.504,P< 0.001), SOFA (r = 0.461,P< 0.001) and CPIS (r = 0.571,P< 0.001) was found. LUS in the pulmonary ARDS group had a positive correlation with CPIS (r = 0.399,P< 0.05), and a positive correlation was found in non-pulmonary ARDS group (r = 0.350,P< 0.05), which indicated that the correlation in pulmonary ARDS was more satisfactory than that in non-pulmonary ARDS. LUS in the pulmonary ARDS group was significantly higher than that in non-pulmonary ARDS group (22.1±4.9 vs. 11.3±2.1,t = 11.667,P< 0.001); LUS in mild, moderate, severe ARDS groups was 9.9±1.7, 14.0±1.4, 23.6±4.1. The predictive value for mild ARDS by LUS was 7.0, sensitivity of 87.0%, specificity of 89.0%; that for moderate ARDS was 11.0, sensitivity of 89.0%, specificity of 87.0%; that for severe ARDS was 8.0, sensitivity of 90.0%, specificity of 88.5%. LUS was 24.3±3.8 in the death group, and 12.7±2.9 in the survival group. Area under ROC curve (AUC) was calculated, and the patients with LUS> 19.0 had a high mortality, sensitivity for predicting death was 84.0%, and specificity of 89.0%.Conclusion Bedside LUS, which is simple and easily available, could evaluate the changes in pulmonary ventilation area of ARDS, and its degree of severity, and prognosis including prediction of mortality of the patients.%目的：探讨肺部超声评分（LUS）对急性呼吸窘迫综合征（ARDS）患者病情严重程度及预后的评估价值，及与氧合指数、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）、序贯器官衰竭评分（SOFA）、临床肺部感染评分（CPIS）等传统参数的相关性。方法采用前瞻性双盲队列研究，入选2013年10月至2014年12月北京华信医院重症加强治疗病房（ICU）符合柏林诊断标准的ARDS患者共62例。其中轻度14例，中度18例，重度30例；肺内源性37例，肺外源性25例；存活35例，死亡27例。一位观察者专门负责收集患者入院时的临床资料及临床评分，包括基线资料、血流动力学参数、乳酸、呼吸参数及APACHEⅡ、SOFA、CPIS评分；另一位观察者专门负责肺部超声检查、LUS评分及超声心动检查。采用双变量相关分析LUS评分与氧合指数、APACHEⅡ评分、SOFA评分、CPIS评分的相关性，采用受试者工作特征曲线（ROC）分别计算LUS评分对轻、中、重度ARDS以及病死率的预测值、敏感度和特异度。结果 LUS评分与氧合指数呈显著负相关（r＝-0.755，P＜0.001），与APACHEⅡ评分（r＝0.504，P＜0.001）、 SOFA评分（r＝0.461，P＜0.001）、 CPIS评分（r＝0.571，P＜0.001）均呈显著正相关；肺内源性、肺外源性ARDS患者LUS评分均与CPIS评分呈显著正相关（r＝0.399、P＜0.05，r＝0.350、P＜0.05），且肺内源性ARDS较肺外源性ARDS的相关性更好。肺内源性ARDS患者LUS评分明显高于肺外源性ARDS患者（分：22.1±4.9比11.3±2.1，t＝11.667，P＜0.001）。轻、中、重度ARDS患者LUS评分分别为（9.9±1.7）、（14.0±1.4）、（23.6±4.1）分；LUS对轻度ARDS的预测值为7.0分，敏感度为87.0%，特异度为89.0%；对中度ARDS的预测值为11.0分，敏感度为89.0%，特异度为87.0%；对重度ARDS的预测值为18.0分，敏感度为90.0%，特异度为88.5%。死亡患者LUS评分为（24.3±3.8）分，存活患者为（12.7±2.9）分；分析ROC曲线下面积（AUC）得出，LUS评分19.0分以上患者病死率高，预测死亡的敏感度为84.0%，特异度为89.0%。结论床旁LUS简单易行，可以评估ARDS患者肺部通气面积的变化，进而评估病情的严重程度，可有效预测患者的预后和病死率。